Infectious Diseases Curriculum/Syllabus

Department of Infectious Diseases (DID) Rawalpindi Medical college and Allied Hospitals 2

Table of Contents

Introduction………………………………………………...... …..3 Overview Of Infectious Diseases Training Program ………...... 5 Inpatient Facilities ……………………………………………………10 Duration Of Training Course ……………………………….…....13 Admission Criteria ………………………………………………….14 MD Job Description..………………………………………………..17 Research/Thesis Writing ………………………………………….21 Methods Of Instruction/Course Conduction ………………… …24 Duration Of Training ……………………………………………...30 Evaluation & Assessment Strategies ……………………………..35 Examinations ………………………………………………………. 38 Curriculum Of Undergraduates …………………………...... 52 Curriculum Of Postgraduates……………………………...... 56 Responsibilities Of Trainees/Students ……………………………..63 Specific Goals ……………………………………………………….68 Infectious Diseases Competencies ………………………………..73 References……………………………………………………………..94

INTRODUCTION

Infectious diseases are caused by pathogenic microorganisms, such as bacteria, viruses, parasites or fungi; the diseases can be spread, directly or indirectly, from one person to another. Zoonotic diseases are infectious diseases of animals that can cause disease when transmitted to humans.

Infectious diseases are one of the leading causes of morbidity and mortality throughout the world especially in developing countries like ours. Amongst all clinical specialties, the infectious diseases department has to be the most 3 vigilant, efficient, organized and active to timely deal with multidisciplinary nature of the infections and not only to treat it but also restrict and confine it.

Department of Infectious Diseases (DID) of Rawalpindi medical College came into existence as an outcome of ingenuity and endeavor of Professor

Muhammad Umar, the principal of Rawalpindi medical College. Recent epidemics of Dengue fever in Punjab accentuated the need and urge for establishment of a state of art, purpose built department of infectious disease that could cater to the effected population of Rawalpindi, through provision of quality health services including accurate and timely diagnosis, efficient management, rehabilitation, in addition to strict control and containment of infection.

Professor Mohammad Umar has the credit initiating this project and has established Department of Infectious diseases of Rawalpindi Medical

College in medical block of Holy Family Hospital, as the first ever such department in the public sector of Pakistan. It has all the available resources and infrastructure to manage the infectious diseases and epidemic threats and has High Dependency Unit, Isolation rooms and general wards.

It will manage all the commonly prevalent infectious diseases of this region with special emphasis on Dengue these years and also the rare or sporadic infections including Ebola, Anthrax, MERS, and SARS etc. 4

Although DID is currently in inception phase, it is thought that continuous efforts will help to make it an exemplary unit in near future. Audits and research focusing infectious diseases treatment in our own scenario will in the long term help in better management of these diseases.

Overview of Infectious Diseases Training Program

Internal Medicine Infectious Diseases Subspecialty Training

Program RMC and Allied Hospitals

The overall goal of the Subspecialty Training Program in Infectious

Diseases is to prepare the trainee for a career as an Infectious Diseases subspecialist

A. Goals of the Clinical Infectious Diseases Trainee Program 5

 To prepare subspecialty residents (residents in Infectious

Disease) in the diagnosis and treatment of adult infectious diseases,

including acute and chronic community acquired infections as well as

nosocomial infections

 To develop the clinical and literature research skills required to

determine the most current information for an individual case.

 To provide experience and education in the proper use of anti-

infective agents.

 To provide expertise in communications with the clinical

microbiology laboratory and anatomic pathology department in the

evaluation of patients with infectious diseases.

 To prepare verbal and written presentations of patient

information, topic review, and current infectious diseases literature.

B. Goals of the Research Infectious Diseases Trainee

 To develop skills in formulating, conducting, analyzing and

reporting clinical and laboratory research projects.

 To prepare the subspecialty resident to independently conduct

clinical or laboratory research projects.

Objectives 6

A. Specific objectives of the Clinical Infectious Diseases Trainee

 Acquire an advanced understanding of host defense

mechanisms and immune responses in relation to infectious diseases

 Acquire an advanced understanding of the etiology,

pathogenesis, diagnosis, and therapy of patients with the following

infectious diseases problems:

1. Fever of unknown origin

2. Fever associated with skin rash

3. Eye infections

4. Upper respiratory tract infections

5. Lower respiratory tract infections

6. Urinary tract infections

7. Intra-abdominal infections

8. Infective endocarditis and intravascular infections

9. Central nervous system infections

10. Gastrointestinal infections

11. Bone and joint infections

12. Sexually transmitted diseases and diseases of the reproductive tract

13. HIV/AIDS 7

14. Hepatitis

15. Skin and soft tissue infections

16. Sepsis and shock syndromes

 Acquire an advanced understanding of common bacterial, viral,

fungal, and other infectious agents and their relationship to clinical

infectious syndromes.

 Acquire an advanced understanding of the etiology, pathogenesis,

diagnosis and therapy of patients with human immunodeficiency virus

infections and associated opportunistic infections.

 Acquire an advanced understanding of the etiology, incidence, and

predisposing factors of nosocomial infections including the management

and maintenance of indwelling vascular catheters.

 Acquire an advanced understanding of infections in special hosts

(transplant recipients, neutropenia patients and HIV infected patients).

 Acquire an advanced understanding of anti-infective therapy

including susceptibility testing, resistance mechanisms,

pharmacodynamics and pharmacokinetics.

 Acquire an advanced understanding of toxins and virulence factors of

infectious agents. 8

 Acquire an advanced understanding of the principles and use of

vaccines.

 Acquire a basic understanding of the principles and methods of

epidemiology in relationship to infectious diseases.

 Acquire a basic understanding of medical ethics in medical practice

and research.

 Acquire a basic understanding of the use of statistics in medical

practice and research.

 Acquire an advanced understanding of infectious agents that have

potential use for bioterrorism.

 Acquire training in system-based medical practice.

B. Specific Objectives of the Research Infectious Diseases

Trainee

 Formulate hypothesis for the selected research proposal.

 Develop methods specific to the research plan, including assessment

of the necessary laboratory tests, groups of animals, or number of

patients using statistical methods. 9

 Understand procedures for obtaining Institutional Review Board

approval by human studies committee if applicable.

 Become proficient in laboratory assays required in the research

proposal.

 Analysis of the data including computer programs, statistical methods,

and tabular and illustrative graphs.

 Formulate the analyzed data into abstract or manuscript form for

presentation and publication.

 Understand ethical issues of human and animal research. INPATIENT FACILITIES

Department of infectious disease is located in basement of Holy

Family Hospital which is a tertiary care hospital, part of RMC and allied hospitals.

A. BED STRENGTH:

 Total Number of beds: 70

 Male: 35 Female: 35

 No. of High Dependency beds in the Unit: 8

 No. of beds (absolute /dedicated) in main intensive care unit

(available for use by the unit): 2 10

 In case of Epidemic of infection Dengue the bed strength can be

extended to 180

B. EQUIPMENT AVAILABLE IN DID:

S. No. Equipment Name Number 1. Oxygen Supply 10 2. Monitor 8 3. Suction Machine 02 4. Glucometer 10 5. E.C.G Machine 01 6. Nebulizer 08 7. Defibrillator 01 8. Mobile X-ray 01 9 Synge Pump 02 10 Infusion Pump 02 11 Ventilator 01 13 Sphygmomanometers 30 14 Portable X ray Machine 01

Ambulatory Care Facilities

There are two outpatient departments of DID, one located in vicinity of

DID department and second in the main OPD complex of HFH hospital. The 11 subspecialty resident has one clinic per week from 8:00am – 02:00pm. The clinic consists principally for conducting outpatient follow-up visits on patients previously hospitalized, for the management of patients on home IV antibiotic, or for the management of HIV infected persons.

In addition, new consultations are seen in these clinics. The subspecialty resident will attend approximately 50 outpatient clinics per year.

The subspecialty residents have primary responsibility for the ambulatory care of Infectious Diseases Clinic patients and hospital follow- up visits. They are always supervised by an attending physician in Infectious

Diseases who will review the care and sign off on each patient visit. It is expected that the subspecialty residents will make the majority of decisions, with difficult decisions made in consultation with the attending physician.

Continuity of care is provided by arranging for subspecialty residents in

Infectious Diseases to maintain an outpatient clinic for the follow-up of patients who were previously evaluated and treated on the inpatient service.

This outpatient clinic is maintained throughout the Subspecialty Residency

Training. This experience includes the continuous management of patients with all stages of HIV infection over a 24 month period. 12

DURATION OF TRAINING COURSE

The duration of training for MD infectious disease is 5 years for candidate who enters after MBBS while it will be 4 years for candidate who has done

FCPS medicine or MD Internal Medicine.

MD Infectious Disease training is structured in three parts

ELIGIBILITY

Root-1

MBBS Degree (Five Year Program)

Quality entry test (Five Year Program)

Root-2 13

FCPS in Internal Medicine (Four Year Program)

ADMISSION CRITERIA

1. For admission in MD course, every candidate shall be required to

have: MBBS degree Completed one year House Job Registration with

PMDC Recommendation of Supervisor Passed Entry Test.

2. Credit for marks in professional examinations, Rural/Army services,

additional experience & published research work may also be

considered on case to case basis.

Regulations 14

1. Scheme of the Courses

A summary of four years course in Internal Medicine & five years course

in special subjects is presented as under:

Entry evaluation

Final examination Part-I Basic medical sciences At the end of 1st year (Anatomy, Physiology Written: and Cell Biology, Paper 1:Basic Science (Anatomy, Biochemistry, General Physiology and Cell Biology, Pathology and Biochemistry, General Pathology Pharmacology) and Pharmacology) Research Methodology Research Methodology and and Biostatistics Biostatistics Fundamental concepts in Paper 2: Principles of Internal Medicine /Principles of Medicine specialty Oral & Practical & Clinical Basic clinical Techniques / OSCE / Structured viva LOG Book / Assignments* Part-II Advanced Professional At the end of 3rd year in internal education in specialty of medicine admission At the end of 4th year in specialty Compulsory/optional medicine rotation in related fields Written: (up to 6 months) Paper 1 & 2: Problem-based questions in the subject Oral & Practical/Clinical Long case/short cases/OSCE LOG Book/Assignments* Part-III Research work/Thesis Thesis Examination at the end of writing o Fourth (4th) Year in Internal Medicine o Fifth (5th) Year in Special Subjects LOG Book/Assignments* 15

*Evaluation shall be done on annual basis

MD JOB DESCRIPTION

The position of Infectious Disease trainee involves evaluation and

management of patients with a diagnosis of infectious diseases and

formal educational and research activities. All of the activities are

supervised by the attending teaching staff. Provision of care provided by 16

the trainee is commensurate with the physician’s level of advancement

and competence.

Part I

Part -1 is structured for the 1st calendar year. For those trainees who have

done only MBBS, they have to complete 1st year in Basic Subject. They

have to clear part-O in basic subjects as well as research methodology

and epidemiology. Those trainees who have done FCPS in medicine, MD

internal Medicine, Part-I in medicine will be exempted.

Part-II

Part II is structured for 2nd, 3rd and 4th Calendar years.

INFECTIOUS DISEASE TRAINEE (YEAR 2, 3) JOB

DESCRIPTION

1. Rounds with Supervisor, or Professor

2. Participation in the weekly outpatient clinic

3. Consultations

4. Teaching of medical students and medical residents

5. Attendance at the conferences, including:

o Infectious Disease Conference

o A course in microbiology

o Weekly infectious disease rounds including outside speakers 17

o Monthly infectious disease radiology conference

o Infectious disease journal club

o Morbidity and mortality rounds

o Infectious Disease research conferences

o Weekly Board review

o Synopsis required for research topic in MD

INFECTIOUS DISEASE TRAINEE (YEAR 4) JOB

DESCRIPTION

a. Demonstrate and perfect primary care and sub-specialty skills in the

care of patients with Infectious disease in the outpatient setting as well

as in the inpatient/consult environment.

b. Polish those interpersonal skills which epitomize a compassionate and

humanistic interaction with patients, families and colleagues.

c. Understanding cost containment issues in the changing environment

of managed care

d. Document research project efforts – clinical or laboratory

e. Attend and participate in educational activities – journal clubs,

didactic conference, multidisciplinary medical-surgical conference, 18

research conference, Infectious disease and internal medicine grand

rounds conferences

f. Perfect teaching skills through supervision of residents and medical

students

g. Perfect ability to critically analyze medical literature

h. Continue working toward completion of the core clinical

competencies program.

Part-III

Qualifications: Trainee must have satisfactorily completed first 3 years of training in the Infectious Disease M.D program.

On successful completion of Part I and Part II the candidate shall spend one calendar year on research and thesis writing.

Compulsory rotations in the relevant fields for 3-6 months

Clinical training experiences are described below:

1. Intensive care units:

On this 3 month rotation, the resident shall develop competence in the differential diagnosis and management of the critically ill, and learn to integrate these clinical skills with the biomedical instrumentation of bedside hemodynamic measurements, right heart catheterization, measurement and computation of gas change variables, cardiac output determination, and all 19 aspects of mechanical ventilation and airway care. These principles, and those governing fluid therapy, nutritional support, and antimicrobial therapy in severely ill patients, shall be reviewed extensively.

2. Outpatient Services

Infectious Disease outpatient training shall be provided during the entire residency in a continuity to review findings and to discuss patient care issues. Residents shall assume primary responsibility for managing their patients.

3. Microbiology

The resident shall learn to prescribe and monitor the different antibiotics antiviral antifungal agents HIV Clinics and TB control Programme rotations

RESEARCH/THESIS WRITING

Total of one year will be allocated for work on a research project with thesis writing. Project must be completed and thesis be submitted before the end of training. Research can be done as one block in 5th year of training or it can be stretched over five years of training in the form of regular periodic 20 rotations during the course as long as total research time is equivalent to one calendar year.

Research Experience

The active research component program must ensure meaningful, supervised research experience will appropriate protected time for each resident while maintaining the essential clinical experience. Recent productivity by the program faculty and by the residents will be required, including publications in peer-reviewed journals residents must learn the design and interpretation of research studies, responsible use of informed consent and research methodology and interpretation of data. The program must provide instruction in the critical assessment of new therapies and of the surgical literature. Resident should be advised and supervised by qualified staff members in the conduct of research.

Clinical Research

Each resident will participate in at least one clinical research study to become familiar with:

1. Research design

2. Research involving human subjects including informed consent and

operations of the institutional Review Board and ethics of human

experimentation. 21

3. Data collection and data analysis

4. Research ethics and honesty

5. Peer review process

This usually is done during the consultation and outpatient clinical rotations.

Case Studies or Literature Reviews

Each resident will write, and submit for publication in a peer-reviewed journal, a case study or literature review on a topic of his /her choice.

Laboratory Research

Bench Research

Participation in laboratory research is at the option of the resident and may be arranged through any faculty member of the Division. When appropriate, the research may be done at other institutions.

Research involving animals

Each resident participating in research involving animals is required to:

1. Become familiar with the patient Rules and Regulations of the

University of Health Science Lahore i.e. those relating to “Health and

Medical Surveillance Program for Laboratory Animal Care

Personnel” and “Care and Use of Vertebrate Animal as Subjects in

Research and Teaching”

2. Read the “Guide for the Care and Use of Laboratory Animals” 22

3. View the videotape of the symposium on Human Animal Care

Research involving Radioactivity

Each resident participating in research involving radioactive materials in required to

1. Attend a Radiation Review session

2. Work with a Authorized User and receive appropriate instruction from

him/her.

METHODS OF INSTRUCTION/COURSE CONDUCTION

As a policy, active participation of students at all levels will be encouraged.

Following teaching modalities will be employed:

1. Lectures

2. Seminar Presentation and Journal Club Presentations 23

3. Group Discussions

4. Grand Rounds

5. Clinico-pathological Conference

6. SEQ as assignments on the content areas

7. Skill teaching in ICU, emergency and ward settings

8. Attend genetic clinics and rounds for at least one month.

9. Attend sessions of genetic counseling

10. Self-study, assignments and use of internet

11. Bedside teaching rounds in ward

12. OPD & Follow up clinics

13. Long and short case presentations

In addition to the conventional teaching methodologies interactive strategies like conference will also be introduced to improve both communication and clinical skills in the upcoming consultant. Conferences must be conducted regularly as scheduled and attended by all available faculty and residents.

Residents must actively request autopsies and participate in formal review of gross and microscopic pathological material from patients who have been under their care. It is essential that residents participate in planning and in conducting conferences. 24

1. Clinical Case Conference

Each resident will be responsible for at least one clinical case conference each month. The cases discussed may be those seen on either the consultation or clinic service or during rotations in specialty areas. The resident, with the advice of the attending Physician on the consultation service, will prepare and present the case(s) and review the relevant literature.

2. Monthly Student Meetings

Each affiliated medical college approved training for MD Infectious Disease will provide a room for student meeting /discussions such as:

 Journal Club Meeting

 Core Curriculum Meetings

 Skill Development a. Journal Club Meeting

A resident will be assigned to present, in depth, a research article or topic of his/her choice of actual or potential broad interest and/or application. Two hours per month should be allocated to discussion of any current articles or topics introduced by any participant. Faculty or outside researchers will be invited to present outlines or results of current research activities. The article should be critically evaluated and its applicable results should be 25 highlighted, which can be incorporated in clinical practice Record of all such articles should be maintained in the relevant department. b. Core Curriculum Meetings

All the core topics of Infectious Disease should be thoroughly discussed during these sessions. The duration of each session should be at least two hours once a month. It should be chaired by the Chief resident (elected by the residents of the relevant discipline). Each resident should be given an opportunity to brainstorm all topics included in the course and to generate new ideas regarding the improvement of the course structure. c. Skill Development

Two hours twice a month should be assigned for learning and practicing clinical skills.

List of skills to be learnt during these sessions is as follows:

1. Residents must develop a comprehensive understanding of the

indications, contraindications, limitations, complications, techniques,

and interpretation of results of those technical procedures integral to

the discipline (mentioned in pg. 10).

2. Residents must have instruction in the evaluation of medical literature,

clinical epidemiology, clinical study design, relative and absolute

risks of disease, medical statistics and medical decision making. 26

3. Training musty include cultural, social, family, behavioral and

economic issues, such as confidentiality of information, indications

for life support systems, and allocation of limited resources.

4. Resident must be taught the social and economic impact of their

decisions on patients, the primary care physician and society. This can

be achieved by attending the bioethics lectures and becoming familiar

with Project Professionalism Manual such as that of the American

Board of Internal Medicine.

5. Resident should have instruction and experience with patient

counseling skills and community education

6. This training should emphasize effective communication techniques

for diverse populations, as well as organizational resources useful for

patient and community education.

7. Resident should have experience in the performance of clinical

laboratory and radionuclide studies and basic laboratory techniques,

including quality control quality assurance and proficiency standards.

8. Each resident will observe and participate in each of the procedures,

preferably done on patients first under supervision and then

independently. 27

3. Annual Grand Meeting

Once a year all resident enrolled for MD infectious disease should be

invited to the annual meeting at UHS Lahore.

One full day will be allocated to this event. All the chief residents from

affiliated institutes will present their annual reports. Issues and concerns

related to their relevant courses will be discussed. Feedback should be

collected and suggestions should be sought in order to involve resident in

decision, making.

The research work done by residents and their literary work may be

displayed.

In the evening an informal gathering and dinner can be arranged. This

will help in creating a sense of belonging and ownership among students

and the faculty. 28

TIME LINE OF ROTATIONS IN DIFFERENT COMPONENTS OF TRAINING PROGRAM DURATION OF TRAINING: 5 YEARS

Part-I In first year the resident will spend 75% of time in learning Year-I of history taking and clinical skill of examining patients. 25% time will be spent in learning. Physiology, Biochemistry and Pathology of Infectious Disease and Biostatistics. Resident who were passed FCPS Medicine will be exempted of year 1 Part-II In year 2 Residents will deal with patients in emergency Year-2 outpatient and in patients, he will also be allowed to do supervision diagnostic procedures. The week I schedule will be as follows for year two  Endoscopy twice weekly 29

 Pathology lab once weekly In year 3 the resident will be having two rotations of 3 Year-3 months each in Pathology (Microbiology) and intensive care unit. The rest of six months will be spent in routine Infectious Disease as in year 1 In year 4 the resident will be having two rotations 3 Year-4 months each HIV clinic TB outdoor clinics. The rest of six months will be spent in routing Infectious Disease as in year 2 and 3 Part-III Research and Thesis working Year-5 Note: Detailed syllabus of MD Training Program can be studied from

document of UHS/UHS Website.

Clinical Rotations for Infectious Disease Training Program

The clinical rotations include out patients rotations. The program is

reviewed periodically and subject to modification.

In patient rotations

The trainee will rotate in Infectious Disease inpatient service. The service

is staffed by full time faculty. Daily round and case discussion,

management and diagnostic issue will be addressed.

Outpatient rotations / emergency rotation

Trainee will have exposure to Infectious diseases emergencies

Radiology Rotation

Trainee will be trained in USG guided procedures and interpretation of

MRI, CT Scan and Barium series. 30

Pathology Rotation

Trainee will examine the Microbiological Microscopic studies observe

the infectious disease serological test and PCR.

Conferences

Trainees are expected to attend several conferences which include the

following

Journal Club

This conference is designed to share important recent publications with

the Infectious Disease trainee while reviewing the elements of study

design utilizing standard critical appraisal techniques.

Recommendations for this conference

1. Choice two to three recent articles from reputable, peer-reviewed

journals.

2. Copy the articles and distribute them to each of the trainees, at least

one week in advance (If possible, provide hypertext links to the

article).

3. Presentations are generally done with just a brief review of the topic

followed by a 15-20 minute review and analysis of each article. The

remaining time is devoted to group discussion.

Research Conference 31

Research conference consists of either one of the Infectious Disease section’s members or a visiting professor discussing his/her current research.

Infectious Disease Clinical Conference

A case based leaning session during which two, 20 minute cases are presented on a rotating basis by Infectious Disease faculty, trainees, and visiting section attending (pediatrics, radiology, and surgery). As a trainee, you will be assigned a topic (rotation) from which to present. These topics are not set in stone – they are only there to guide you. Standard presentations should involve 5-7 minutes of case information, 10-15 minutes of pertinent literature review, with the remaining time for discussion and debate. Pointers for this conference:

1. Keep the literature review focused on the specific problem, and resist

the urge to review more general issues

2. Review your presentation with your faculty member before the

conference

3. Don’t be derailed by the active discussion which invariably develops

4. Power point presentations are encouraged.

5. Include radiographic, endoscopic & pathology images when pertinent

Senior Resident lecture series 32

Each 3rd year resident is responsible to preparing a lecture about a topic of their choice. House officers are encouraged to pick controversial topics and make the lectures evidence based. House officers receive a list of expectations prior to beginning to help prepare them for their talk. Each resident picks a faculty mentor. This mentor helps the resident prepare their presentation and participates actively in the conference.

Evaluation per UHS guidelines

EVALUATION & ASSESSMENT STRATEGIES

Assessment 33

It will consist of action and professional growth oriented student-centered integrated assessment with an additional component of informal internal assessment, formative assessment and measurement based summative assessment.

Student-Centered Integrated Assessment

It views students as decision-makers in need of information about their own performance. Integrated Assessment is meant to give students responsibility for deciding what to evaluate, as well as how to evaluate it, encourages students to ‘own’ the evaluation and to use it as a basis for self- improvement, Therefore, it tends to be growth-oriented, student-controlled, collaborative, dynamic, contextualized, informal, flexible and action- oriented.

In the proposed curriculum, it will be based on:

 Self-Assessment by the Student

 Peer Assessment

 Informal Internal Assessment by the Faculty

Self-Assessment by the Student

Each Student will be provided with a pre-designed self-assessment form to evaluate his/her level of comfort and competency in dealing with different relevant clinical situations. It will be the responsibility of the student to 34 correctly identify his/her areas of weakness and to take appropriate measure to address those weaknesses.

Peer Assessment

The students will also be expected to evaluate their peers after the monthly small group meeting. These should be followed by a constructive feedback according to the prescribed guidelines and should be non-judgmental in nature. This will enable students to become good mentors in future.

Informal Internal Assessment by the Faculty

There will be no formal allocation of marks for the component of Internal

Assessment so that students are willing to confront their weaknesses rather than hiding them from their instructors.

It will include:

a. Punctuality

b. Ward work

c. Monthly assessment (written tests to indicate particular areas of

weaknesses)

d. Participation in interactive sessions

Formative Assessment

Will help to improve the existing Instructional methods and the curriculum in use 35

Feedback to the faculty by the student:

After every three months students will be providing a written feedback regarding their course component and teaching methods. This will be help to identify strengths and weaknesses of the relevant course, faculty members and to ascertain areas for further improvement.

Summative Assessment

It will be carried out at the end of the Programme to empirically evaluate cognitive, psychomotor and affective domains in order to award degrees for successful completion of courses.

EXAMINATIONS

Part-I Examination: 36

All candidates admitted in MD degree course shall appear in Part-I examination at the end of first calendar year.

The examination shall be held on biannual basis.

The candidate is expected to pass this examination in four attempts.

The candidate who fails to pass the examination in four attempts or within 3 years of enrolment shall be dropped from the course.

The examination shall have three components:

 Written

 Oral & practical / clinical examination.

 Log Book Evaluation

There shall be two written papers of 100 marks each:

Paper 1: Basic Sciences relevant to the specialty (Anatomy, Physiology,

Biochemistry, General Pathology, and Pharmacology) / Research

Methodology & Biostatistics

Paper 2: Principles of Internal Medicine

The types of questions shall be of Short/Modified essay type and /or MCQs

(single best). The question pertaining to Research Methodology &

Biostatistics may be of descriptive nature.

Oral & practical / clinical examination shall be held in basic clinical techniques relevant to Medicine and special subjects. 37

To be declared successful in Part-I examination the candidate must secure

60% marks in each component (written and practical), and 50% in each sub- component

To be eligible to appear in Part-I examination the candidate must submit:

Application duly recommended by the Supervisor

Certificate by the Supervisor that candidate has attended at least 75% of the

Lectures, seminars, practical / clinical demonstrations

Examination fee as prescribed by the University

Exemptions: A candidate holding FCPS/MRCP / equivalent qualification shall be exempted from Part-I examination.

Part-II Examination

All candidate admitted in MD course shall appear in Part-II examination at the end of structured training Programme (end of 3rd calendar year in

Internal Medicine and end of 4th calendar year in subspecialty).

The examination shall be held twice a year.

The Part-II examination shall have following components:

Written 300 marks

Oral & Practical / Clinical 300 marks 38

Log Book 200* marks

* 50 marks per year in 4 years program

* 40 marks per year in 5 years Programme

There shall be two written papers of 150 marks each. Both papers shall have problem-based Short/Modified essay questions and /or MCQs. To be declared successful in Part-II examination the candidate must secure 60% marks in each component (written and practical)

Oral & Practical / Clinical examinations shall have 300 marks for

# Marks

Long Case 1 100

Short Cases 4 100

OSCE/Structured viva 100

Log Book/Assignments:

Throughout the length of the course, the performance of the candidate shall be recorded on the Log Book. 39

The Supervisor shall certify every year that the Log Book is being maintained and signed regularly.

The Log Book will be developed & approved by the Advanced Studies &

Research Board.

The evaluation will be maintained by the supervisor (in consultation with the

Co-Supervisor, if appointed).

The performance of the candidate shall be evaluated on annual basis, e.g. 50 marks for each year in a four year course and 40 marks for each year in a five year course. The total marks for Log Book shall be 200. The Log Book shall reflect the performance of the candidate on following parameters:

Year wise record of the competence of skills.

Year wise record of the assignments.

Year wise record of the evaluation regarding attitude & Behavior.

Year wise record of journal club, lectures and clinico-pathological conference attended.

To be eligible to appear in Part0II examination the candidate must submitz:

Application duly recommended by the Supervisor.

Certificate by the Supervisor that the candidate has completed the prescribed period of training of the course and has attended at least 75% of the lectures, seminars and practical/clinical demonstrations. 40

Original Log Book complete in all respect and duly signed by both the

Supervisor and Co-Supervisor (during Oral & practical /clinical).

Certificate that the candidate has passed Part-I Examination.

Examination fee as prescribed by the University.

Board of Examiners

The part-II examination shall be conducted by a board of four examiners preferably examiners from other universities and from abroad. The senior examiner of the subject will be Convener of the Board. The examiners shall be appointed from respective specialties. Specialists from Internal Medicine and related fields may also be appointed/co-opted in special subjects where deemed necessary.

All examiners shall equal responsibilities as examiners, except the

Convenor, who shall be responsible for conducting the examination and submitting the result to the Controller of Examinations on the same day at the end of examination in University.

A candidate must be assessed by each examiner of board independently without consultation with the others.

Part III submission / Evaluation of Synopsis: 41

The applicants shall prepare synopsis for the thesis as per guidelines provided by the advanced studies and research board.

The research topic in clinical subject should have 30% component related to basic sciences and 70% component related to applied clinical sciences. The research topic must consist of a reasonable sample size and sufficient numbers of variables to give training to the candidate to conduct research, to acquire & analyze the data.

Synopsis of research project shall be submitted during the first 12 months of course. The synopsis shall be submitted through the supervisor/s, the

Principal/Dean of the institution. The synopsis shall be evaluated by the following Committee: Principal/Dean or his representative Chairman

Supervisor of the student Member /Secretary a Professor nominated by the

Principal Member.

After the approval by the Committee, the synopsis shall be submitted to the respective Review Committee of the University for consideration by the

Advanced studies & Research Board.

Part-IV (Thesis) Examination 42

All candidates admitted in MD courses shall appear in Part-III (thesis examination) after 1 year of completion of Part-II examination and not later than 8th Calendar year of enrolment

Only those candidates shall be eligible for thesis evaluation that have passed

Part-II examination

The examination shall include thesis evaluation with defense.

Submission of Thesis:

Thesis shall be submitted by the candidate duly recommended by the

Supervisor.

The minimum duration between approval of synopsis and submission of thesis shall be one year.

The research thesis must be ring-bound in accordance with the specifications of the academic council of the university.

Four copies of the thesis shall be submitted I year after Part-II examination but not later than 8 years of enrolment.

The research thesis will be submitted along with fee prescribed by the

University.

The evaluation and Defense of the Thesis 43

The thesis shall be examined by three examiners, at least one from abroad, appointed by the University for Part-III Examination. Each of the examiners will be provided a copy of the thesis at least thirty days before the defense.

The candidate will appear for defense before the panel of examiners in the presence of Supervisor / Co-Supervisor on a fixed date and will have to successfully defend the thesis. Total marks of thesis evaluation will be 200.

The distribution of marks will be 66 marks for each of two examiner & 68 with the Convenor Examiner.

Declaration of Result.

The candidates who have passed written, oral and practical (OSCE) and clinical examinations separately shall be declared pass.

The candidates, who have passed written examination but failed in oral and practical/clinical examination, will re-appear only in oral & Practical

/clinical examination.

The maximum number of attempts to re-appear in oral and practical /clinical shall be three, after which the candidate shall have to appear in both written and oral and practical/clinical, as a whole. 44

The candidate must obtain 60% marks in each component to pass the examination.

The candidate with 80% or above marks shall be deemed to have passed with distinction.

Award of MD Degree.

After successful completion of the structured courses of MD and qualifying

Part-I, Part-II and Part-III examinations, the degree of MD with title shall be awarded, e.g. MD Infectious Diseases 45

MD INFECTIOUS DISEASE EXAMINATION PART-I MD INFECTIOUS DISEASE

TOTAL MARKS: 100

All candidates admitted in MD infectious disease course shall appear in Part

I examination at the end of first calendar year.

There shall be one written paper of 100 marks

Topics included in paper

1. Anatomy History and Embryology 20 MCQs

2. Physiology 20 MCQs

3. Pathology 25 MCQs

4. Biochemistry 10 MCQs

5. Pharmacology 10 MCQs

6. Behavioral Sciences 10 MCQs

7. Biostatistics and Research Methodology 05 MCQs

Components of Paper

MCQ Paper 100 one best type

Total Marks 100

PART-II MD INFECTIOUS DISEASE 46

TOTAL MARKS: 380

All candidates admitted in MD infectious disease course shall appear in Part

II examination at the end of 2nd calendar year.

There shall be two written paper of 100 marks each, structured clinical viva of 100 marks and log book assessment of 80 marks.

Topics included in paper 1

Principles of internal medicine including:

1. Pulmonary Medicine 10 MCQs

2. Allergy and Immunology 10 MCQs

3. Cardiovascular Illness 10 MCQs

4. Endocrinology and Metabolism 10 MCQs

5. Ophthalmology & Otolaryngology 05 MCQs

6. Infectious Disease 05 MCQs

Topics included in paper 2

Principles of internal medicine including:

1. Nephrology 10 MCQs

2. Neurology 10 MCQs

3. Hematology & Gastroenterology 10 MCQs

4. Dermatology 10 MCQs 47

5. Rheumatology 10 MCQs

Components of Part II Examination

Theory:

Paper 1: Total Marks 3

10 SEQS (No Choice; 5 marks each) 50 Marks

50 MCQs 50 Marks

Paper 2

10 SEQS (No Choice; 5 marks each) 50 Marks

50 MCQs 50 Marks

The candidates, who pass in theory papers, will be eligible to appear in the structured viva voce.

OSCE 100 Marks

10 stations each are carrying 10 marks of 10 minutes duration; each evaluating performance based assessment with five of them interactive.

Log Book 80 Marks 48

PART III MD INFECTIOUS DISEASE

TOTAL MARKS: 920

All candidates admitted in MD Infectious Disease course shall appear in Part

III examination at the end of structured training Programme (end of 5th calendar year and after clearing Part I & II examination)

There shall be two written papers of 150 marks each practical/clinical examination of 300 marks, log book assessment of 120 marks and thesis examination of 200 marks.

Components of Part III Examination

Theory:

Paper I: 150 Marks 3 Hours

15 SEQ (No Choice) 75 Marks

75 MCQs 75 Marks

Paper II 150 Marks 3 Hours

15 SEQS (No Choice) 75 Marks

75 MCQs 75 Marks 49

The candidates, who pass in theory papers, will be eligible to appear in the clinical & viva voce.

OSCE/Viva 100 Marks

10 stations each carrying 10 marks of 10 minutes duration: each evaluating performance based assessment with five of them interactive.

Clinical 200 Marks

Four short cases (each 25 marks) 100 Marks

One long case 100 Marks

Log Book 120 Marks

Thesis Examination 200 Marks

All candidates admitted in MD courses shall appear in Part III thesis examination at the end of 5th calendar year of MD Programme and not later than 7th calendar of enrolment. The examination shall include thesis evaluation with defense. 50

THE CURRICULUM OF INFECTIOUS DISEASES FOR UNDERGRADUATES AT DID

The course outline followed for teaching of undergraduates of Rawalpindi

Medical College at Department of Infectious Diseases, as per requirement of

University of Health Sciences, Lahore is as follows:

CLINICAL SYNDROMES.

1. Sepsis and septic shock,

2. Meningococcemia

3. Acute infectious diarrheal diseases and bacterial food poisoning.

4. Hospital acquired infections.

Common disease syndromes caused by the following bacteria and their drug therapy:

1. Pneumococci

2. Staphylococci.

3. Streptococci.

4. Hemophilis influenzae.

5. Shigella.

6. Gonococci.

7. Pseudomonas. 51

Following diseases in detail:

1. Tetanus.

2. Enteric fever/salmonellosis.

3. Cholera.

4. Tuberculosis.

5. Leprosy.

6. Amoebiasis/giardiasis/trichomoniasis.

7. Malaria.

8. AIDS.

9. Rabies.

10. Infectious mononucleosis.

Helminthic infestations:

1. Ascariasis

2. Hookworm

3. Whipworm (Trichuriasis)

4. Threadworm (Entrobiasis)

5. Taenia (Tapeworm)

6. Hydatid Diseases

Undergraduates should be made capable of understanding the following

Symptomatology to reach the Differential Diagnosis: 52

1. Fever

2. Headache, pain o Anorexia/ weight loss

3. Hemoptysis/ chest pain/ epigastric

4. Cough/expectoration/sputum

5. Dysuria, pyuria

6. Diarrhea / vomiting

7. Melena, hematemesis

8. Jaundice/hepatomegaly

9. Eruption and rashes

10. Itching

11. Joint pain and joint swelling etc.

Skills to Be Learnt:

1. History taking and correlate with a specific diagnosis.

2. Examination and assessment of the pattern of fever, involvement of

organ systems and any positive findings.

3. Interpretation of related radiological and laboratory investigations

4. Symptomatic treatment and prescription writing in infectious diseases.

Procedures:

Perform:

1. Injection I/V, I/M, S/C, intradermal 53

2. Oxygen therapy

3. Urinary catheterization – collection of samples

4. Collection of blood samples/ blood film preparation

Observe:

1. Observe I/V lines/Fluids/Blood/Blood products, direct, canula,

cutdown, CVP

2. N/G tube passing and feeding

3. Foley’s catheter/Red rubber catheter

4. Intake output record maintenance

5. Aspiration of fluids (Pleural, Pericardial, Peritoneal, Knee)

6. Lumbar Puncture

7. O2 therapy

8. Nebulization etc. 54

CURRICULUM OF INFECTIOUS DISEASES FOR POST GRADUATES

The course outline followed for teaching of post graduate trainees undergraduates of Rawalpindi Medical College at Department of Infectious

Diseases, as per requirement of College of Physicians And Surgeons,

Pakistan is as follows:

CORE CURRICULA FOR CPSP FELLOWSHIP/ MD PROGRAM

UHS IN INFECTIOUS DISEASES

Knowledge areas:

Fundamental principles

1. Microbial virulence factors

2. Host defense mechanisms

3. Epidemiology of infectious diseases

4. Anti-infective therapy - principles

Approach to Clinical Microbiology

1. Appropriate collection and transport of specimens

2. Sterilization and disinfection

3. Microscopy

4. Staining (Gram, AFB, others) 55

5. Culture media and basic preparation

6. Culture techniques (standard and automated)

7. Bacterial and mycobacterial microbiology

8. Sensitivity testing

9. Parasitology

10. Mycology

11. Molecular diagnostics

12. Virology

13. Safety

14. Quality assurance

Management of Major Infectious Clinical Syndromes

1. Fever evaluation

2. Respiratory tract infections

3. Cardiovascular infections

4. Central nervous system infections

5. Skin and soft tissue infections

6. Gastrointestinal infections, food poisoning and hepatitis

7. Bone and joint infections

8. Diseases of the reproductive organs and sexually transmitted diseases 56

9. Eye and ENT infections

10. Infections in other organ systems

11. Acquired immunodeficiency syndrome

12. Infections in immune compromised hosts and burns

13. Transplant infections

14. Nosocomial infections

15. Infections in special hosts

16. Surgical and trauma-related infections

17. Zoonoses

18. Miscellaneous syndromes

Specific Pathogens

1. Viral diseases and Prions

2. Chlamydial and Mycoplasma diseases

3. Rickettsioses and ehrlichioses

4. Bacterial diseases

5. Mycoses

6. Protozoal diseases

7. Diseases due to toxic algae

8. Diseases due to Helminths and ectoparasites 57

Special Topics

1. Immunization

2. Infection control

3. Risk reduction

4. Outbreak investigation

5. Travel medicine

6. Biological warfare

7. Health economics

8. Use of information resources

9. Biostatics

10. Evaluation of literature

11. Medical writing and funding sources

12. Medical ethics

Diagnostics – exposure to be embedded in clinical rotations

 Interpretation of radiology and nuclear medicine techniques in

consultation with specialists in those areas

 Interpretation of pathologic diagnoses relevant to infections and

inflammation in consultation with pathologists

CORE COMPETENCIES 58

A specialist must possess varied and complex skills. The level of competence to be achieved, as specified according to the key, is follows:

1. Observer status

2. Assistant status

3. Performed under supervision

4. Performed under indirect supervision

5. Performed independently

COMPETENCY LEVELS IN PATIENT MANAGEMENT

Following competencies should be achieved at end of part II with level 5 performance ( performed independently) :-

COMPETENCIES A: Patient Management Formulating a working diagnosis Deciding about ambulatory Care/hospitalization referral Ordering investigation and interpreting them Deciding & implementing treatment Maintaining follow-up of patients B: Procedures Bacteriology Perform Gram Stain Interpret Gram stain of Blood, sterile fluids and sputum Interpret culture plates Inoculation of culture plates Interpret antimicrobial susceptibility testing (Disc diffusion, 59

MIC) Interpret API Mycobacteriology Perform AFB smear Interpret AFB smear Interpret AFB Cultures Urinalysis Perform and interpret Urine Dipstick Mycology Identification of Molds and yeasts Serology Interpretation of serologies Perform RPR Interpret RPR Perform MP ICT Interpret MP ICT 60

RESPONSIBILITIES OF TRAINEES/STUDENTS

Each subspecialty resident has at least one twenty-four hour period every 7 days free of any clinical responsibilities. Coverage is provided by other subspecialty residents within the program.

Outlined below are the responsibilities of the student, specialty resident and subspecialty resident when they are participating in the Clinical

Infectious Disease Training. The responsibilities of the individual team members are within the guidelines of the teaching mission and the service mission.

1. If both subspecialty residents and specialty residents are rotating on the

Infectious Diseases Service, the specialty resident will share the patient responsibilities with the Infectious Diseases subspecialty resident responsible for administrative matters and for teaching as well as patient care. 61

2. A subspecialty resident and/or specialty resident will be on call for infectious diseases consultations seven days a week. The call schedule for the specialty resident and subspecialty resident will be made by the head of department. A subspecialty resident will be on call every day of the month.

In general there is no night call for the specialty resident when a subspecialty resident is on service. However, the Internal Medicine specialty resident will be expected to be available if educational opportunities present themselves or if there is a service requirement in the absence of a subspecialty resident.

If there is no subspecialty resident on service during the month the specialty resident will take call on a regular basis.

3. Follow-up visits for inpatients will be coordinated by the sub-specialty resident responsible for the patient’s care while in hospital.

4. Medical students may be assigned to the subspecialty resident and/or specialty resident. The students will be active members of the consult team and will be supervised by the subspecialty residents and specialty residents.

Every attempt will be made to have the student see the patient first or simultaneously with a resident. A student may choose to be on call with the subspecialty resident and specialty resident, but this is not mandatory.

Students are not required to be present on weekend or holidays. 62

5. When possible, the resident will see new and ongoing cases before the

Infectious Diseases faculty attending. At times, it may be beneficial for the attending physician and the team to see the patient together, or the attending physician may prefer to see the patient first, but every attempt will be made for the resident to see the patient initially. The organization of the clinical service may vary depending on the assigned attending physician for that month.

6. Admissions to unit will be seen by the residents. For the most part, these patients are admitted through the Infectious Diseases Clinics and is the responsibility of the admitting resident to write the notes and orders on their patients.

7. Rounds will be made on each patient each day

8. It is of utmost importance to know exactly the status of laboratory data.

Information such as “the results are not back” (in the chart) is unacceptable.

9. There are a number of ongoing clinical studies that require awareness of the Infectious Diseases team. The infectious diseases faculty will inform you of these various studies so that we may enroll patients.

10. Current Topics in Infectious Diseases Conference will be held every

Monday morning promptly at 8 am. The resident,/student in the department of Infectious Diseases are required to attend and participate in this 63 conference. The quality of presentations will be considered in the evaluation of DID residents/students.

11. Residents/ students will attend the Infectious Diseases Conference on each Wednesday at 8:00 am .

12. Infectious Diseases Clinics are to be attended by the subspecialty resident. They will be supervised by the scheduled faculty member.

13. The resident is responsible for managing reliever anytime for which they are not available

14. It is recommended that generic names be used whenever possible instead of trade names when discussing medications, especially antibiotics (e.g. ceftazidime instead of Fortum).

15 The residents and students will have a formal didactic lecture series each rotation.

16 Each member of the team should try to manage a variety of patients to provide for a wider background in the types and presentations of infectious diseases.

Lecture Topics:

 Antibiotics 64

 Viruses and Antiviral Agents

 Fungi and Antifungal Agents

 Meningitis and Brain Abscess

 Pneumonia

 Endocarditis

 Hepatitis

 Skin and soft Tissue Infections

 STDs

 HIV

 TB and Mycobacteria other than MTB

 Rickettsia

 Parasites and Malaria

 Infection Control

 Vaccinations

The overall goal of the inpatient experience is to educate the trainee in the diagnosis and management of routine and complex adult infectious diseases and prepare them for a career as an Infectious Disease specialist. An additional goal is to gradually and progressively increase responsibility and 65 decision making for the trainee in order to prepare them to be qualified for independent management of inpatient infectious diseases.

SPECIFIC GOALS

1. Patient Care

 Be capable of accurate, comprehensive patient evaluations, including

history, physical examination and data review

 Ensure that clinical decisions are made on available evidence, sound

judgment, and individual patient factors

2. Medical Knowledge

 Acquire an advanced understanding of host defense mechanisms and

immune responses to infectious agents

 Acquire an advanced understanding of the etiology, pathogenesis,

diagnosis and therapy of patients with infectious diseases

 Acquire an advanced understanding of infections in

immunosuppressed hosts

 Acquire advanced expertise in anti-infective therapy including

mechanism of action, resistance mechanisms, pharmacokinetics and

pharmacodynamics

3. Practice Based Learning and Improvement 66

 Develop skills in problem based learning and improvement

 Effectively utilize feedback to improve patient care and decision

making

 Demonstrate progressive improvement in performance based on

review of practice pattern

 Incorporate new practice information and recommendations to guide

improvement of clinical Care.

4. Intrapersonal and Communication Skills

 Demonstrate accurate and concise communication with patients,

family, attending physicians, and hospital personnel

 Demonstrate prompt and appropriate communication with home care

and clinic personnel for outpatient follow-up, including accurate

documentation in the medical record

 Demonstrate the ability to work with the entire inpatient care team

(attending physician, postgraduate physicians, medical students, hospital

personnel, and home care coordinators)

5. Professionalism

 Develop and maintain appropriate levels of ethical, moral, and

professional behavior 67

 Demonstrate appropriate respect and behavior to all patients and

families

 Demonstrate a commitment to ethical principles pertaining to

confidentiality

6. Systems Based Practice

 Acquire expertise in systems based practice

 Interact effectively with patient, family, pharmacy, case managers,

and home care personnel in arranging outpatient intravenous

antimicrobial therapy

 Interact effectively with patients, case managers, pharmacy, social

work personnel, and clinic staff in the care of patients with HIV

Teaching Methods

 Text book reading

 Small group discussions

 Web based information

 Review of current literature

 Journal Club

 Clinical Conference 68

 Research Conference

 Immunology Review conference

 Internal Medicine Grand Rounds

Authority to Isolate

1. First the attending physician orders the appropriate isolation for the patient.

2. If the attending physician is unavailable to isolate then infectious control focal person will do so by documenting in the Physician’s

Progress Notes: a. Request for specific isolation b. Reason isolation is necessary

Employee Health

Infection Control aspects of Employee Health are addressed by the Infection

Control Committee.

Policies and Procedures (Departmental) 69

Policies and procedures related to aseptic, isolation, and sanitation techniques are developed for all clinical areas and approved by the Infection

Control Committee.

Hospital Disposal System

1. The evaluation of the Hospital disposal system for all liquid and solid wastes is performed by infection control committee. An Infection Control

Practitioner is a standing member of this committee.

2. The Waste management Program is reviewed, revised and approved by the Infection Control Committee.

Other Functions

 Evaluate Hospital departmental effectiveness of incorporating

Infection Control Committee guidelines in the formulation of policy

and the execution of procedures

Recommend changes in the Infection Control Committee Program as necessary to ensure correction of recognized deficiencies not addressed or resolved. 70

INFECTIOUS DISEASES COMPETENCIES

At the completion of training, the resident will have acquired the following competencies and will function effectively as a:

A) Medical Expert

Definition:

As Medical Experts, Infectious Diseases physicians integrate all of the

Roles, applying medical knowledge, clinical skills, and professional attitudes in their provision of patient-centered care. Medical Expert is the central physician Role in the framework.

Key and Enabling Competencies: Specialists in Infectious Diseases are able to… 71

1. Function effectively as consultants, integrating all of the Roles to provide optimal, ethical and patient-centered medical care

 Perform a consultation effectively, including the presentation of well-

documented assessments and recommendations in written and/or

verbal form in response to a request from another health care

professional

 Demonstrate effective use of all competencies relevant to the practice

of Infectious Diseases

 Identify and appropriately respond to relevant ethical issues arising in

patient care

 Demonstrate the ability to prioritize professional duties when faced

with multiple patients and problems

 Recognize that the nature of infectious diseases, including outbreaks,

is unpredictable, making it important that the Infectious Diseases

physician be able to demonstrate flexibility and strong prioritization

skills

 Demonstrate compassionate and patient-centered care

 Recognize and respond to the ethical dimensions in medical decision-

making 72

 Demonstrate medical expertise in situations other than direct patient

care, such as providing expert legal testimony, advising governments,

infection prevention and control, public health as it relates to

infectious diseases, and antimicrobial stewardship.

2. Establish and maintain clinical knowledge, skills and attitudes appropriate to the practice of Infectious Diseases

 Apply knowledge of the clinical, socio-behavioural, and fundamental

biomedical sciences relevant to Infectious Diseases

 Describe the framework of competencies relevant to Infectious

Diseases

 Apply lifelong learning skills of the Scholar to implement a personal

program to keep up-to-date, and enhance areas of professional

competence.

 Contribute to the enhancement of quality care and patient safety in

Infectious Diseases, integrating the best available evidence and best

practices

3. Perform a complete and appropriate assessment of a patient

 Identify and explore issues to be addressed in a patient encounter

effectively, including the patient’s context and preferences 73

 Elicit a history that is relevant, concise and accurate to context and

preferences for the purposes of prevention and health promotion,

diagnosis and/or management.

 Perform a focused physical examination that is relevant and accurate

for the purposes of diagnosis and/or management

 Select medically appropriate investigative methods in a resource-

effective and ethical manner

 Demonstrate effective clinical problem solving and judgment to

address patient problems, including interpreting available data and

integrating information to generate differential diagnoses and

management plans

4. Use preventive and therapeutic interventions effectively

 Implement a management plan in collaboration with a patient, family

and consulting health professional

 Demonstrate effective, appropriate, and timely application of

preventive and therapeutic interventions

 Ensure appropriate informed consent is obtained for investigations

and therapies

 Ensure patients receive appropriate end of life care 74

5. Demonstrate proficient and appropriate use of procedural skills, both diagnostic and therapeutic:

 Demonstrate effective, appropriate, and timely performance of

diagnostic procedures relevant to Infectious Diseases

 Ensure appropriate informed consent is obtained for procedures

 Document and disseminate information related to procedures

performed and their outcomes

 Ensure adequate follow-up is arranged for procedures performed

6. Seek appropriate and timely consultation from other health professionals, recognizing the limits of their own expertise

 Demonstrate insight into their own limits of expertise

 Demonstrate effective, appropriate, and timely consultation of another

health professional as needed for optimal patient care

 Arrange appropriate follow-up care services for a patient and the

patient’s family

B) Communicator

Definition: 75

As Communicators, Infectious Diseases physicians effectively facilitate the doctor-patient relationship and the dynamic exchanges that occur before, during, and after the medical encounter.

Key and Enabling Competencies: Specialists in Infectious Diseases are able to…

1. Develop rapport, trust, and ethical therapeutic relationships with

patients and families

 Recognize that being a good communicator is a core clinical skill, and

that effective communication can foster patient and physician

satisfaction, adherence and improved outcomes

 Recognize that patients may identify individuals other than family

members as their significant supports

 Demonstrate a positive, non-judgmental attitude towards patients and

their families/supports

 Respect patient confidentiality, privacy and autonomy

 Counsel and support patients with newly diagnosed infection,

particularly those infections that are chronic, potentially stigmatizing,

or contagious to others

 Listen effectively and obtain and synthesize relevant history from

patients, families/supports, and communities 76

 Be aware of and responsive to nonverbal cues

 Facilitate a structured clinical encounter effectively

 Demonstrate respect for patients, their families/supports, and their

value systems and health care preferences, which may be different

from one’s own values

 Elicit and accurately synthesize relevant information and perspectives

of patients and families/supports, colleagues, and other professionals

 Gather information about illness, as well as the patient’s beliefs,

concerns, expectations and illness experience

 Seek out information about cultural beliefs that may impact on the

patient’s health from resources such as cultural associations and

support agencies

 Recognize the impact of such factors as age, gender, sexual

preference, ethno cultural background, social support, alternative

health care practices, financial support, education, and emotional

influences on a patient’s illness

2. Convey relevant information and explanations to patients and families/supports, colleagues, and other professionals

 Deliver information in a manner that is understandable, respectful,

and encourages discussion and participation in decision-making 77

 Address challenging communication issues effectively, such as

obtaining informed consent, delivering bad news, complying with

public health reporting requirements and contact tracing, and

addressing anger, confusion and misunderstanding

3. Develop a common understanding on issues, problems and plans with patients, families/supports, and other professionals to develop a shared plan of care

 Identify and explore problems to be addressed from a patient

encounter effectively, including the patient’s context, responses,

concerns, and preferences

 Respect diversity and difference, including but not limited to the

impact of gender, sexual orientation, religion and cultural beliefs in

decision making

 Encourage discussion, questions, and interaction in the encounter

 Engage patients, families, and relevant health professionals in shared

decision-making to develop a plan of care

4. Convey effective oral and written information about a medical encounter  Maintain clear, concise, accurate, and appropriate records of clinical

encounters with rationale (written or electronic) for plans

 Present verbal reports of clinical encounters and plans 78

5. Demonstrate understanding of the principles guiding communication with the public and media

 Recognize those topics that are likely to be of public interest, such as

communicable disease outbreaks, immunizations, antimicrobial

resistance, and potential threats such as bioterrorism and pandemic

infections

 Contribute to the development of patient/public education/information

 Convey information in a manner that is accurate and easily understood

C) Collaborator

Definition:

As Collaborators, Infectious Diseases physicians effectively work within a health care team to achieve optimal patient care.

1. Participate effectively and appropriately in an interprofessional health care team

 Describe the subspecialist’s roles and responsibilities to other

professionals 79

 Describe the roles and responsibilities of other professionals in the

health care team, including:

 Recognize and respect the diversity of roles, responsibilities and

competencies of other professionals in relation to their own

 Work with others to assess, plan, provide and integrate care for

individuals and groups of patients

 Work with others to assess, plan, provide and review other tasks, such

as research problems, educational work, program review or

administrative responsibilities

 Participate in interprofessional team meetings

 Enter into collaborative relationships with other professionals for the

provision of quality care, functioning within the principles of team

dynamics

 Describe the principles of team dynamics

 Respect team ethics, including confidentiality, resource allocation and

professionalism

 Demonstrate leadership in a health care team, as appropriate

2. Work with other health professionals effectively to prevent, negotiate, and resolve interprofessional conflict 80

 Demonstrate a respectful attitude towards other colleagues and

members of an interprofessional team

 Work with other professionals to prevent conflicts

 Employ collaborative negotiation to resolve conflicts

 Respect differences and address misunderstandings and limitations

with other professionals

 Recognize one’s own differences, misunderstandings and limitations

that may contribute to interprofessional tension

 Reflect on interprofessional team function

D) Manager

Definition:

As Managers, Infectious Diseases physicians are integral participants in health care organizations, organizing sustainable practices, making decisions about allocating resources, and contributing to the effectiveness of the health care system.

1. Participate in activities that contribute to the effectiveness of their

health care organizations and systems

 Work collaboratively with others in their organizations 81

 Participate in systemic quality process evaluation and improvement,

such as patient safety initiatives

 Describe the structure and function of the health care system as it

relates to Infectious Diseases, including the roles of physicians

 Describe principles of health care financing, including physician

remuneration, budgeting and organizational funding

2. Manage their practice and career effectively

 Set priorities and manage time to balance patient care, practice

requirements, outside activities and personal life

 Manage a practice including finances and human resources

 Implement processes to ensure personal practice improvement

 Employ information technology appropriately for patient care

3. Allocate finite health care resources appropriately

 Recognize the importance of just allocation of health care resources,

balancing effectiveness, efficiency and access with optimal patient

care .

 Apply evidence and management processes for cost-appropriate care

4. Serve in administration and leadership roles, as appropriate

 Chair or participate effectively in committees and meetings

 Lead or implement change in health care 82

 Plan relevant elements of health care delivery (including work

schedules)

E) Health Advocate

Definition:

As Health Advocates, Infectious Diseases physicians responsibly use their expertise and influence to advance the health and well-being of individual patients, communities, and populations.

1. Respond to individual patient health needs and issues as part of patient care

 Identify the health needs of an individual patient

 Identify opportunities for advocacy, health promotion and disease

prevention with individuals to whom they provide care

 Appreciate the possibility of competing interests between individual

advocacy issues and the community at large

2. Respond to the health needs of the communities that they serve  Describe the practice communities that they serve 83

 Identify opportunities for advocacy, health promotion and disease

prevention in the communities that they serve, and respond

appropriately

 Appreciate the possibility of competing interests among governments,

communities served, and other populations, such as government

policy in conflict with evidence supporting risk reduction

interventions

3. Identify the determinants of health for the populations that they serve

 Identify the psychological, social, and physical determinants of health

of the populations that they serve, including barriers to achieving

optimum health and access to care and resources

 Identify vulnerable or marginalized populations, including but not

limited to immigrants and those at risk for HIV, tuberculosis, and

sexually transmitted diseases, and respond appropriately

4. Promote the health of individual patients, communities, and populations

 Describe an approach to implementing change in a determinant of

health of the populations they serve

 Describe how public policy impacts on the health of the populations

served 84

 Identify points of influence in the health care system and its structure

 Describe the ethical and professional issues inherent in health

advocacy, including altruism, social justice, autonomy, integrity and

idealism

 Recognize that isolation and quarantine measures to prevent the

spread of infection may interfere with the patient’s autonomy, liberty

and quality of care

 Recognize that legislated reporting requirements for infectious

diseases may place the physician in conflict with the patient’s desire

for confidentiality and privacy

 Appreciate the possibility of conflict inherent in their role as a health

advocate for a patient or community with that of manager or

gatekeeper

 Describe the role of the medical profession in advocating collectively

for health and patient safety

F) Scholar

Definition: 85

As Scholars, Infectious Diseases physicians demonstrate a lifelong commitment to reflective learning, as well as the creation, dissemination, application and translation of medical knowledge.

1. Maintain and enhance professional activities through ongoing learning

 Demonstrate knowledge of the principles of maintenance of

competence

 Describe the principles and strategies for implementing a personal

knowledge management system

 Recognize and reflect on learning issues in practice

 Conduct a personal practice audit

 Pose an appropriate learning question

 Access and interpret the relevant evidence

 Integrate new learning into practice

 Evaluate the impact of any change in practice

 Document the learning process

2. Critically evaluate medical information and its sources, and apply this appropriately to practice decisions 86

 Describe the principles of critical appraisal

 Critically appraise retrieved evidence in order to address a clinical

question

 Integrate critical appraisal conclusions into clinical care

3. Facilitate the learning of patients, families, students, residents, other health professionals, the public and others, as appropriate

 Describe principles of learning relevant to medical education

 Describe the principles of adult learning

 Discuss teaching models for patient and colleague education

 Identify collaboratively the learning needs and desired learning

outcomes of others

 Select effective teaching strategies and content to facilitate others’

learning

 Demonstrate an effective lecture or presentation

 Assess and reflect on a teaching encounter

 Provide effective feedback

 Evaluate the knowledge, skills, and competence of junior learners on

the infectious diseases service

 Describe the principles of ethics with respect to teaching 87

4. Contribute to the development, dissemination, and translation of new knowledge and practices

 Describe the principles of research and scholarly inquiry

 Describe the principles of research ethics

 Pose a scholarly clinical or research infectious disease question

 Conduct a systematic search for evidence to identify gaps in

knowledge around the clinical or research question

 Select and apply appropriate methods to answer the question

 Disseminate scientific and/or medical information in the peer

reviewed literature

 Implement a solution in practice, where appropriate

 Complete a scholarly project relevant to Infectious Diseases that is

suitable for peer-reviewed publication or presentation at a national

academic meeting

G) Professional

Definition: 88

As Professionals, Infectious Diseases physicians are committed to the health and well-being of individuals and society through ethical practice, profession-led regulation, and high personal standards of behavior.

1. Demonstrate a commitment to their patients, profession, and society through ethical practice

 Exhibit appropriate professional behaviors in practice, including

honesty, integrity, commitment, compassion, respect, an appreciation

of diversity, and altruism

 Demonstrate a commitment to delivering the highest quality care and

maintenance of competence

 Recognize and appropriately respond to ethical issues encountered in

Infectious Diseases, such as informed consent, advanced directives,

confidentiality, end of life care, isolation and quarantine, and dealing

with individuals who may put others at risk by virtue of their sexual

practices or other behaviors.

 Demonstrate ethical decision-making processes

 Manage conflicts of interest appropriately 89

 Recognize the principles and limits of patient confidentiality as

defined by professional practice standards and the law

 Maintain appropriate professional relationships with patients

 Demonstrate tolerance for ambiguity, uncertainty, and the possibility

of error in decision-making; demonstrate flexibility and willingness to

adjust appropriately to changing circumstances

2. Demonstrate a commitment to their patients, profession and

society through participation in profession-led regulation

 Demonstrate knowledge and an understanding of the professional,

legal and ethical codes of practice.

 Fulfill the regulatory and legal obligations required of current practice

 Demonstrate accountability to professional regulatory bodies

 Recognize and respond to others’ unprofessional behaviours in

practice

 Participate in peer review

3. Demonstrate a commitment to physician health and sustainable

practice

 Balance personal and professional priorities to ensure personal health

and a sustainable practice

 Strive to heighten personal and professional awareness and insight 90

 Recognize other professionals in need and respond appropriately

References 91

1. “ Objectives of Training in the Subspecialty of Infectious Diseases”2012 The Royal College of Physicians and Surgeons of Canada

2. Overview of Infectious Diseases Training Program Internal Medicine Infectious Diseases Subspecialty Training Program Saint Louis University School of Medicine

3. Infectious Disease Fellowship Training Program Division of Infectious Disease Department of Medicine Wendy Armstrong, MD, Emory University

4. http://www.uhs.edu.pk/